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by Arthur Caplan, Ph.D.

As Americans enter 2014 there is grave concern among our political leaders that we are lagging behind other nations in terms of our children’s’ scientific literacy.  This past December an international survey confirmed—too many American kids don’t understand science and they continue to fall behind children from other nations, many much poorer than we are in science and math skills.

Students in the United States slipped deeper in the last international science literacy rankings amid fast-growing competition abroad.  American teens scored below the international average in math and roughly average in science, compared against dozens of other countries in the 2012 Program for International Student Assessment (PISA). …

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12/30/2013 Making Choices
  New Year resolutions are sometimes easy to make but hard to keep. Resolutions are choices, choices to live on and to better ourselves. For patients who are critically ill, resolve is often in short supply.  So, to physicians reading this I ...

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12/30/2013 Making Choices

New Year resolutions are sometimes easy to make but hard to keep. Resolutions are choices, choices to live on and to better ourselves. For patients who are critically ill, resolve is often in short supply.  So, to physicians reading this I ask that one of your resolutions this coming year is to speak with patients about their end of life choices and help other physicians do the same. Many physicians are either reluctant to broach the subject, or not very good at discussing these issues, or both. Many feel that they will “cross that bridge when they get to it,”...

The post Making Choices appeared first on Clinical Bioethics Blog.

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by Craig Klugman, Ph.D.

This has been a rich year for depictions of end-of-life and assisted living  in television this year. Back in August, I reported on a PBS series looking at life in assisted living and just last month I wrote about a Showtime documentary series about people at the end of life. The year in television is also ending with another show about the end-of-life, this one produced by HBO where all 6 episodes are available. Getting On is the story of 3 nurses and their demoted medical director, who run a woman’s rehabilitation unit affiliated with a hospital.…

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A father brings his young son to the doctor for prescription medications because the father suspects that the son has "classic" attention deficit/hyperactivity disorder.The  mother relates to the hospital emergency room with  a history of mul...

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by Arthur Caplan Ph.D.

Concepts matter in doing the right thing in medicine.  This could not be more obvious then the utter confusion on display over the concepts of ‘brain death’ and ‘life support technology’ that has resulted in two dead people being kept on artificial life support in California and Texas.

In Oakland, California 13 year old Jahiu McMath has been maintained on machines since an elective tonsillectomy went horribly wrong on December 9.  She has been in the ICU on life-support at the Children’s Hospital since then.

In Forth Worth, Texas, Marlese Munoz has been on machine support in the ICU at JPS Hospital since, without any warning, last November 26th, she suffered a pulmonary embolism. …

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It is all about the role of government is setting limits on what you eat and how you live your own life vs government being simply a teacher, an instructor of the facts and allow its public to live their own personal lives as they see fit.  The recent limit-setting regulations of food, drink and other health issues by Michael Bloomberg as the previous mayor of New York city  has provoked controversy both for and against these actions.  A series of articles in Bioethics Forum, website of  The Hastings Center, bioethics "think tank",  presents views regarding this controversy.   Lawrence O. Goslin (University Professor and Founding O’Neill Chair in Global Health Law at Georgetown University Law Center, and a Hastings Center Fellow) writes "Bloomberg's Health Legacy: Urban Innovator or Meddling Nanny", originally published in the Hastings Center Report September-October 2013,  with the following Abstract.

Michael Bloomberg assumed office as the 108th mayor of New York City on January 1, 2002. As he leaves the mayoralty—having won re—election twice-his public health legacy is bitterly contested. The public health community views him as an urban innovator—a rare political and business leader willing to fight for a built environment conducive to healthier, safer lifestyles. To his detractors, Bloomberg epitomizes a meddling nanny—an elitist dictating to largely poor and working—class people about how they ought to lead their lives. His policies have sparked intense public, corporate, and political ire—critical of sweeping mayoral power to socially engineer the city and its inhabitants.

Here, I seek to show how Bloomberg has fundamentally changed public health policy and discourse. He has used the engine of government to make New York City a laboratory for innovation-raising the visibility of public health, testing policy effectiveness, and probing the boundaries of state power. Even though the courts have blocked some of his boldest initiatives, he has offered a paradigm for the “new public health”—reaching beyond infectious diseases to upstream risk factors in everyday life and the human habitat. I also critically probe various arguments designed to derail his policies, along with the overarching charge of unjustified paternalism.

Apparently, after much negative feedback Goslin received about the article supporting Bloomberg, he wrote his response to the Bioethics Forum titled "Bloomberg’s Health Legacy: What Inflames Consumer Passions in the Food Wars? Goslin argues for some governmental control with the following:

Making the healthy choice is exceedingly hard, with so many forces pointing in the direction of cheap, accessible, aggressively marketed food, alcohol, and tobacco. Consumers, far from having unconstrained choices under the status quo, are actually heavily influenced in their purchasing and lifestyle decisions.

In a semi-rebuttal article written to the Bioethics Forum, Ann Barnhill, an assistant professor in the Department of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania, states:

While I agree with this analysis, I think it is incomplete. The charge that Bloomberg is a meddling nanny reflects not just distrust with government influence on our lives; it also expresses indignation at Bloomberg’s putative attitude towards us: like little children being minded by a nanny, we can’t be trusted to make decisions for ourselves. What troubles some citizens about Bloomberg’s policies is not just the material impact of these policies on their choices and pocketbooks but also the symbolic value of these policies.

Go and read the complete short articles and then return and tell us what you think of government setting regulations regarding what we eat and what we drink and even more personal choices.   ..Maurice.

Graphic: Nanny State. Expression from and graphic created by me using ArtRage and Picasa 3.

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Bandy X. Lee, M.D.

*Primum non nocere*, to first do no harm, is the unchanging foundation for Hippocratic medical ethics. Each generation must, nevertheless, redefine what “doing no harm” means for its time. As we are making historic transitions in healthcare in the U.S., now is such a time for our generation.

“Doing no harm” means first avoiding doing the most extreme harm—that is, violence. Meanwhile, it is important to note that our understanding of what constitutes violence has also been expanding: the multi-determined nature of violence, no matter the scale, point to causal dynamics beyond the immediately apparent. The greatest predictor for interpersonal violence levels, for instance, turns out to be societal inequities in income and wealth.…

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The recent loss of Nelson Mandela’s physical life pushed me to write the first essay in the three topic series I have planned for a while. The topics are 1) Heroes and Super Heroes, 2) Aging and 3) Dying on film.  As it happens, his life made significant contributions in each of these areas.   My hope is to juxtapose the different ways these ethical tensions are made accessible on the screen across generations, genres and platforms; adults x children, drama x comedy, live action x animation, film x television, large screen x small screen. The goal is that various age cohorts and clinicians will consider moving out of their comfort zones and view new formats and genres.  Hopefully better screen literacy will help cross cultures and generations and provide better bioethics and clinical medical ethics. Away we go into Bioethics Screen Reflections for 2014!

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I saw the United States premiere of MANDELA: LONG WALK TO FREEDOM at the Mill Valley Film Festival on October 9, 2013. I have been thinking about the film for two months, having read the autobiography, from which it was adapted nearly twenty years before. LONG WALK TO FREEDOM, directed by Justin Chadwick and screenplay written by William Nicholson, had an enormous task; to follow the lead of an eminently literate, political humanist in a film genre which contradicts the main character’s essence.   Actor Edris Alba plays Mr. Mandela wielding the full scope of self-reflection, commitment and fallibility. 

If a hero has to be perfect, then no one can aspire to the job. If a film must be flawless, all would be unwatchable.  Super Heroes save others and are endowed with powers making them godlike. The ability for individuals to identify with Mandiba’s fallible human character in the film will likely be of more value, in inspiring others to leadership, than simply heaping accolades in memorial to his considerable uniqueness. His fallibility does not detract from his human hero status, nor did it prevent him from freeing himself and in so doing enabling others to do so as well. This is the true mark of the human hero story. They are usually recruited to struggles reluctantly; forced to overcome apparent insurmountable obstacles with a group of confidants (or at very least one.) Think Don Quixote.

There are at least two bioethical conflicts illustrated by this film; One being a beneficence concern and the other a justice concern. The need to depict a significant leader without portraying him as a god is a beneficence issue. Unfortunately it is anathema for a film about a hero. It may be difficult for audiences to get their heads around.  This even though, our science and humanities knowledge tells us when men are deemed greater than human, the outcome for human development is poor. Mr. Mandela walked that line cautiously and so tried the film.

The issue of equitable distribution of benefits and burdens, or justice, is raised in key relationships between Mandiba and his family; in side of prison; ultimately those who were exiled and those who stayed on the home front. It is a fundamental issue in those who commit themselves to humanitarian struggle that they are public beyond the apparent immediate needs of their families, though in service of both.  Sorting out whether you are to provide for the care of your family or be the agent of their care is an issue in many careers sharing borders with struggle.

It is an important part of film literacy for viewers and teachers of bioethics to understand the role of genre. Audiences defined genre. The ways in which they respond to how films "present" stories, creates the marketed. The strength of the allegiance of the filmmakers to genre defines the works monetary potential and so production potential. Projected monetary success determines the probability of a film seeing the light of projection. The often noted hypocrisy of the major film industry products is in fact determined by what viewers support and do not support. The standard changes only when viewers demand it.

The 'Biopic' or biography-picture genre focuses on the ‘star.’  The star of a film is the character who undergoes the most change. By this standard one could argue actor Naomie Harris’ Winnie Mandela portrayal would make her the star of this film. Mandiba is shown confident, pensive and rational throughout the first two-thirds of the film. It is through her suffering that he begins to struggle with the details of the ethical conflicts associated with the effects of the demands of choosing a life of struggle, on family.  However, she is more than family, she is a comrade in arms so shares the same conflict. 

LONG WALK TO FREEDOM works against its genre, because the nation of South Africa is the true primary character, not Mr. Mandela.  The films difficulty deepens because the filmmaker and screenwriter had to make a star movie out of the story of a man whose historical record shows he did not cast himself as a star, but as a drafted leader in a cadre of equally strong heroes.
I suspect there was enormous hand wringing over the film’s diminished depiction of the cadre to which Mr. Mandela historically belonged; giving only a passing nod to the extraordinary likes of Oliver Tambo, Brahm Fischer and Walter Sisulu. The movement for one person one vote in South Africa was not dependent on Mr. Mandela alone. Would that it and struggles to come be so simple. The longing of the average person for simplicity sends patrons to the theater. It is our job to use film as a device helping people understand more deeply and finding resonance of the work within themselves. This has been the purpose of all storytelling throughout human history. When we see these issues in clinics with overwhelmed parents, in colleagues and so on, suggest films that may help.

It is hard to make a film whose main character seeks to defy the adoration of the chosen genre, but I am glad Chadwick struggled to do so with MANDELA: LONG WALK TO FREEDOM. 

Mandela Long Walk to Freedom (35mm) directed by Justin Chadwick. UK. The Weinstein Company. 2013.

For further information read:
Mandela, Nelson. Long Walk to Freedom. Little Brown & Co. 1994.
A brief history of the African national Congress.    accessed December 12, 2013

Zoe Elton. Mandela: Long Walk to Freedom / ; accessed December 13, 2013

Museum of the African Diaspora was the sponsor of the MVFF screen of MANDELA LONG WALK TO FREEDOM see:

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